[Care pathways] are the geographic maps of managed care. [They] eliminate the boundaries of time and space by removing the walls within a health care setting. [They] rattle our needs for ‘turf’ and revise our ideas of territory. [They] help us chart the way for truly patient-centred care (Etheridge 1986: 1–3).
There is and can be no such thing as a purely objective map, one that reproduces a pre-existing reality. Choices always have to be made about what to represent and how, and what to leave out. To be included on the map is to be granted the status of reality or importance. To be left off is to be denied (King 1996: 18).
An Emperor wishes to have a perfectly accurate map of the empire made. The project leads the country to ruins – the entire population devotes all its energy to cartography (Borges 1984: 325).
Maps are increasingly understood as socio-cultural and political constructs, rather than mirrors of nature. Drawing on the insights of cultural cartographers, this paper presents a critical analysis of a specific instance of map-making in health policy, namely the growing use of care pathways in care planning and service delivery. Widely regarded to date as devices for ensuring quality of care, equity of treatment, optimal resource allocation and a rational division of labour between healthcare professionals, they have been seen as helpful – and technically neutral – tools for routing patients through the system. By contrast, we argue that the metaphors are misleading: lived experience and its objectification in pathway maps continually re-create one another, as we explore the slippage between map, map-making and mapping. This paper is based on interviews and observations with a variety of healthcare workers in three areas of south eastern England. We trace the development of a series of pathways-in-process, and show how they configure the patient, highlighting some aspects of their experiences, whilst silencing others. We also analyse the role of pathways in the carving up and surveillance of space round the emergence of the ‘hybrid professional’, particularly new practitioners such as GP specialists, specialist nurses, extended scope therapists and others. In considering the wider implications of care pathways as part of the contemporary discourse on policy, the paper critiques the rationalist, and sometimes evangelical assumptions underpinning their current popularity. In particular, we suggest that a critical and processual understanding of pathways might contribute to a more informed appreciation of their potential (and their limitations) as mechanisms for healthcare policy implementation.
A recent exhibition at the British Library, seductively entitled ‘The Lie of the Land’, illustrated how the appeal of maps lies in the way they hover between fact and fiction. They are not mirrors of nature. Whilst ostensibly timeless, universal and objective, they may better be seen as powerful rhetorical tools imposing their own linear order on to spaces and events. Rather than representing complex behaviours and relationships, they present only inert fixtures from which agency and intentionality have disappeared, history has been erased. De Certeau (1984) puts the matter beautifully: ‘Itself visible /the map/has the effect of making invisible the operation that made it possible . . . /In transforming/action into legibility, it causes a way of being in the world to be forgotten’ (1984: 121).
What maps silence is just as interesting as what they make visible, for this says a great deal about the compilers of maps, and the difficulties of penetrating the unseen structures which shape people's lives (Wood 1992, King 1996, Black 1997). In cautioning us against mistaking the map for the territory, theorists have powerfully argued that whilst territory may be authoritatively mapped, it can never be truthfully mapped (Harvey 1992).
But more is at stake. As ideological constructs, maps are laced with interests, with at least an eye on re-distributing resources and advancing sectional interests, licensing certain forms of intervention and marginalising (or excluding) others. The questions that maps pose are thus moral as well as epistemological. If maps reflect and sustain power relationships, how might an understanding of mapping and map use as processes of knowledge construction (as opposed to knowledge transfer) enable them to be used positively to promote social justice?
It is precisely these tensions that form the subject matter of this paper. We approach them dialectically through an analysis of the interplay between maps as quasi-objective tools or faits accomplis, the practice of map-making (the compiling of maps), and the process of reflecting on that practice, that we term ‘mapping’ (Ingold 2000). This interplay offers a window on the way that maps produce their reality effect ‘as long as they are confirmed in their existence by means of recursive acts of belief and practical investment’ (Pels 2002: 69).
Health policy, like many other areas of contemporary governance, has not been immune to this proliferation of map-making (Abbott 1988). Techniques of gene mapping, the development of protocols, decision-tree analyses, G.I.S. (geographical information systems), diagnostic and treatment algorithms, and process modelling can all be seen as instances of the mapping process in healthcare, which have as much to do with administering healthcare as understanding the social complexities to which administration gives rise. This paper is concerned, however, with a specific instance of map-making in health policy, namely the burgeoning use of care pathways1. From almost nowhere, apparently, they appear to have become the tool of choice for ensuring (or so it is claimed) quality of care, equity of treatment, optimal allocation of resources and a rational division of labour between healthcare professionals. Simultaneously, it is claimed that they respond even-handedly to concerns for patient safety, variable healthcare quality and spiralling health costs (Bragato and Jacobs 2003).
Care pathways embody an approach to organisations, whose intellectual origins can be traced back at least to the Enlightenment's social engineering model of society with its twin beliefs in constant improvement and rationality. This organisational engineering tradition was manifest in the classical management theory of the late 19th century (Fayol 1949) and in scientific management in the 1920's (Taylor 1911), surfacing again in the form of business process re-engineering in the 1990s (Hammer and Champy 1993). (See McNulty and Ferlie (2002) for a critical case study of BPR in a UK hospital.) In many respects, care pathways are direct descendants of the time-task matrix approach of Gantt charts, developed by Henry Gantt (one of Taylor's assistants) in the early 1890s (Bragato and Jacobs 2003). They emerged in the 1980s in the USA in the context of the development of managed care, as a management tool for rationalising resource utilisation and meeting length of stay parameters imposed by third-party healthcare funders. Originally (1985) ‘timelines’ (Etheridge 1986), they evolved into ‘critical paths’ (Woldrum 1987), and by 1990, had been transformed into the ‘CareMaps™ System’ (Zander 1991). Along the way, what had started out as a tool for planning just nursing care had grown to become ‘the core of the entire patient care-giving process and its documentation by all disciplines (our emphases)’ (Zander 1991). At the same time (in an apposite reminder of the closeness of the link between map-making and territorial expansionism), the organisation promoting them itself metamorphosed from The Center for Nursing Case Management into The Center for Case Management.
In the UK, interest in care pathways had begun to emerge piece-meal in the mid-1990s, but the real impetus to their development came with the publication of the White Paper, The New NHS: Modern and Dependable (Department of Health 1997). Although it did not refer specifically to care pathways, its aims (national standards, local flexibility, efficiency, quality, patient centred-ness) are strikingly similar to the claims made for pathways (Norris and Briggs 1999).
Website hits have to be viewed as enigmatic artefacts rather than reliable indicators of adoption and use. Nonetheless, they suggest a growing interest in care pathways (Table 1). By 2004, search of the National Electronic Library for Health (NHS Information Authority 2004) revealed records of 237 pathways, spanning the alphabet from abscess via mental health to wrist surgery. Interest in them has been further fuelled by a number of other recent policy developments. These include the drive to standardise professional performance in an era troubled by revelations of professional misconduct post-Shipman, and the shift from professional discretion and variability to a more rules-based, audited practice (Power 1997, Strathern 2000). Further factors in their promotion have been the thrust towards joined-up services (Department of Health 2000) and the constant remaking of professional boundaries, in pursuit of workforce flexibility and professional de-regulation (Gellner and Hirsch 2001). They have also been advocated as a means of making service provision more patient-centred. However, despite their growing popularity, consideration of care pathways to date has been limited, even in the clinical literature, where they have been treated uncritically as helpful (and technically neutral) tools rather than embodied practices for routing patients through the system (Campbell et al. 1998, Owen 1998, Parker 1999). The only reservations that have been voiced about them concern the lack of robust evidence of their effectiveness (Campbell et al. 1998).
Theoretically, this paper draws on a variety of sources, such as Berg's analysis of protocols and medical standardisation (Berg 1997, Berg et al. 2000) and Bowker and Leigh Starr's (2000) work on expert classification systems, that view them as embodied practices rather than concrete ‘things’. In it we explore how pathways are being envisaged, worked and transformed in the new NHS, and their implications for the way patient and professional subjectivities are currently being fashioned. First, we examine how care pathways de-couple the patient from his/her context, highlighting some aspects of the patient experience, while silencing others. Second, we consider the role of pathways in re-defining inter-professional relationships, especially around the emergent ‘hybrid professionals’, such as GP specialists, specialist nurses, extended-scope physiotherapists and others. Third, we draw out some of the wider implications (both positive and negative) of pathways as part of the simplifying and disciplinary activity of the state, before offering some cautionary comments about the over-rationalist and sometimes evangelical impetus behind the pathway movement. While not arguing against rational planning per se, we suggest a more modest approach to the possibilities of incorporating pathways into the design of patient care. In particular, we suggest that a critical and processual understanding of pathways – a process cartography (Rundstrom 1993) – might contribute to a more informed appreciation of their potential (and their limitations) as mechanisms for healthcare policy implementation.
Mapping the field: methods, setting and subjects
This study was part of a wider investigation of the referral strategies of the recently created primary care organisations in the ‘new NHS’. Its setting was three Primary Care Trusts in the Greater London area, which had been identified (through briefings by regional administrators) as innovators in this respect. One (‘Brown’) was suburban with a large rural hinterland, one (‘Fleming’) was semi-rural and one metropolitan (‘Jameson’). All three were involved in the process of developing care pathways or else had their development under active consideration. They thus constituted a purposive selection of ‘leading edge’ primary care organisations in this respect. Interviews were conducted over a period of five months with 25 health professionals and administrators. Three were consultants, eight GPs (including four GP clinical governance and commissioning leads and one GP specialist), one an optometrist, one a public health doctor, one a nurse manager and 11 were PCT Board members. Where informed consent was given, interviews were tape-recorded and transcribed verbatim. In the three instances when consent was withheld, contemporary shorthand notes were taken, which were subsequently transcribed in full. Observations made during site visits and interviews were recorded in shorthand and written up in a fieldwork diary. Interviews and fieldwork notes were written up into interim case study vignettes, which were returned to interviewees for their comments.
Qualitative work in the health services has been appropriately critiqued for the banality of many of its findings (Lambert and McKevitt 2002). The highly stylised, performative nature of the single interview, for example, offers little scope on its own for exploring the tacit meanings so rarely explicated between people, or the way that meanings are always in process of becoming something else. Meaning does not lie on the tip of the tongue. Anthropological studies of organisations have identified profound discrepancies between how people conceive of their organisation and their actual practice, and the inability of rationalist frameworks to capture the subtle, imaginative and symbolic ways people have found to deal with the inconsistencies and contradictions that arise (Ouroussoff 2001: 37).
To deepen our understanding and explore the inevitable slippages between what people said they thought and did and what they ‘actually’ thought and did, we observed the clinics of an extended scope physiotherapist (ESP), an ophthalmic nurse practitioner, and a specialist dermatology nurse in Brown. We also observed a PCT Board meeting there. In addition to formal observation, we took opportunistic advantage of the occasions for informal observation that arose during fieldwork. The demands of the larger study meant that we were able to investigate only the initial stages of a number of pathways in process, or under active consideration by the PCTs concerned. We were not able to see the process through to official ‘completion’ or to analyse the finished product. Nevertheless, we did have the opportunity to ask the key health professionals involved in the process to draw their maps, to reflect on them and to articulate some of the assumptions that were built into them. In so doing, we were able to explore the dialectic between maps, map-making and mapping referred to above. We also acknowledge that our representations (Figure 1) are, of necessity, cleaned up and re-ordered versions of what was drawn roughly at interview. Behind the apparent certainties of our lines and arrows and boxes, there lay layers of meaning that were highly conditional, contingent and uncertain.
The study also raised questions about the scope for exploratory research which generates hypotheses rather than merely seeking to confirm pre-existing criteria (Gellner and Hirsch 2001, Agar 1996, Wolcott 1999). As always, gaining access to policy makers is necessarily a sensitive issue. Doors simultaneously opened and closed, and the lead researcher found her contacts carefully orchestrated. In Brown County, for example, a GP specialist was brought in from his annual leave; whereas no amount of negotiation allowed entrée to the ENT consultant at Fleming.
Finally, a perception amongst some participants of research as a practical management tool was at odds with lower key attempts to unravel process. The Director of Services at Brown County wanted the study to identify ‘five things we’re doing well and five challenges’, whilst the Chief Executive of Fleming County enquired about the publication of results only three months after completion of interviewing there. Difficult questions are raised too about the anticipated use of research to raise organisational profiles. What is the acceptable face of any criticism? Increasingly, qualitative research risks being co-opted not to sensitively illuminate practice, but to proffer simple solutions to complex problems, possibly reproducing the very power structures it needs to challenge in doing so. Weaving a pathway (sic) between these imperatives is the stuff of contemporary health services research.
Exploring the pathway
The pathway and the patient
As with all protocols, it is tempting to view the rationalising and atomising practices of the care pathway as objective and value free (Berg 1997). When, however, managers and practitioners discussed their maps, they revealed a trail of unspoken assumptions, which betrayed their partiality. Figure 1 presents six competing versions of a care pathway (for patients with cataracts), that were elicited or volunteered by different stakeholders in the three healthcare settings.
What is immediately striking about these pathways is how different they are, particularly in respect of which profession occupies prime position (which we discuss below). Despite these differences, there are also important underlying similarities. The first is their tendency towards simplification. This is clearest in maps (i) and (ii) which present the illusion (at least) of closure. They depict a simple, idealised pathway for patients with cataracts, with single start- and end-points, without turnings or crossroads, or choice of routes. All of the pathways also abstract the patient and reify the condition. Predicated on a biomedical and essentialist model of the patient, they all define their situation by their impairment, simplifying the complexity of their lives and reducing their treatment to the clinical disposal of discrete bodily parts. Finally, they assume a large-batch, high-turnover model of healthcare, as the Director of Services at Brown explained:
It's an easily diagnosable condition, there's lots of them around and it's quite straightforward. There's a large cohort of people all needing the same thing, they need to be funnelled through a process . . . with cataracts what you've got, it's something has happened to their eye. It's like changing the exhaust on your car. When you've had your exhaust changed, you’re absolutely fine. Episode over.
He acknowledged that this model of care might not have been feasible for chronic conditions where variability in impairment or co-morbidities might complicate the picture. However, by their nature, cataracts lent themselves to the development of a care pathway:
With a chronic disease it's more difficult. That would be a problem with a pathway. There's a lot of people in those circumstances who might be very different. Whereas a patient with a cataract, a cataract is a cataract is a cataract. You can quite nicely develop a pathway for that.
Yet even with cataracts, the consultant ophthalmologist at Brown acknowledged that patients in different circumstances would need different treatment:
There are going to be different visual requirements between those who are at home and no longer do any night driving or sewing – that's one thing that gets missed to a certain extent here.
Although it was recognised that variations in age, ethnicity and social class would profoundly affect how patients would experience even a comparatively straightforward condition such as cataracts, these features were admitted into the landscape of care only as after-thoughts. Missing from the maps was any appreciation of how these factors might affect not just the patient experience, but the types and quantities of care required. Also absent was any recognition of the vital role played by informal carers. Ingold's (2000) point about the activity of mapping is nicely illustrated here. The more the maps aimed to furnish a precise, systematic representation of reality, the less true to life they became. Paradoxically it was knowing the detail, not eliminating it, that allowed the practitioner to find his/her way around, and avoid the pitfalls.
Observation and interviews revealed that the one-stop pathway for cataracts relied totally on patients’ friends and relatives to administer the post-operative eye-drops. Elderly and disabled patients living on their own, for example, would require referral to the district nurse and intermediate care team, as a GP at Jameson acknowledged (Map v):
The problem is, even if this works perfectly, and yes, the patient does need a cataract surgery, they have one stop at the clinic here, go on the list and have the operation, things go wrong here. Like the patients don't get their eye drops because the hospital pharmacy's closed the day they’re sent home, so they’re down here the next day saying, ‘They want me to have some eye drops’, or, ‘Oh, I dropped the bottle’, or ‘They've run out’, or ‘I need a prescription’, or ‘I've got pain and they haven't given me any painkillers’, or ‘I can't put the drops in because I'm blind or elderly or disabled and who's going to do it?’ And so the District Nurse needs to go in. These are the sorts of things that can go wrong . . .
Once these features began to be admitted to the landscape, the care pathway became more complicated. What had started out as a one-size-fits-all model of professionally-delivered care turned out to be dependent for its success upon a complex (and unmapped) network of relatives, friends and informal carers in the community. As soon as the contingencies of patients’ lives were overlaid onto the hard rectangles and straight lines of the pathway, the illusion of authoritativeness began to crumble, prompting an exasperated ‘It's quite complex, it's supposed to be simple’ from the opthalmologist who had been key in promoting the cataract pathway at Brown. The contingent, arbitrary and mechanistic nature of the map was exposed, as the following comment indicates:
Well I mean it's almost robotic. Ideally I think they would just like to send the eye off and operate on the cataract and then send it back to the patient . . . The whole point about pathways is that they adopt a reductionist view, that you can reduce things just to the cataract and remove them from the rest of the patient's life. I know that patients like to know what's happening, they like to be talked to about it, and they like to understand it and assimilate it, and that doesn't often happen in a pathway (Commissioning lead GP, Fleming).
Nominally, pathways located patients at their centre, treating them as active participants in the care process rather than its passive objects. Certainly, health practitioners appeared to feel that they were expected to demonstrate the patient-centredness of their proposals. Thus, in the preamble to his pathway the consultant opthalmologist commented, ‘Essentially I’ll do it from the patient's point of view’. Yet only one pathway indicated how matters might look if the patient were placed at its centre (Map (vi)) and even here, patient empowerment turned out to be illusory.
It's interesting because the whole aspect people forget about in demand management is the patient aspect. I'd put the patient in the middle and then put all the people acting on him (our emphasis) (GP Special Projects Lead, Jameson).
We found little evidence that patients had either been involved or consulted in the process of pathway development. In respect of pathways, as in the NHS in general, as the Chief Executive in Fleming acknowledged, patient involvement or consultation was ‘tokenism’. An agenda item at a conference on pathways at Brown read, ‘Results of patient survey – if time permits’. (Time did not permit, with the result that patients’ views were not considered.) The Jameson nurse educator concluded,
Care pathways aren't integrated with the person, but with the provision of care.
and the Brown optometrist conceded that vested professional interests limited the extent to which pathways could ever genuinely be patient-centred:
They can't be patient-centred. Not really. If they were patient-centred, the consultant would say (ironically), ‘Go bring them forth, and I will see to them’. The consultant has this great big pyramid below him which keeps him where he is. And no one wants to push him off, because a good consultant is worth his weight in gold.
In all of the maps (but perhaps most clearly in the linear pathways of maps (i) and (ii)) a certain sleight of hand was discernible. By appearing to be cleansed of interests and value-free, the different versions of the pathways gave the impression that all interests represented in them (professionals, patients, employing institutions) were identical and could be simultaneously served. Thus, practitioners enthused about pathways as ‘efficient for all concerned’ (Chair, PCT, Fleming), or ‘No one's the loser: it's a win-win situation all round’ (Dermatology Consultant, Brown). However, once these assumptions began to be probed, questions arose:
Doctor: The argument is that you’re making it easier for the patient, you’re wasting less time, but it really often is just to make the service more efficient so that you see more patients.
RPi: So who are these pathways for?
Doctor: Well I think they are to try and speed things up for patients, but they really are to help the institution run more efficiently I think. They give the impression that they’re very straightforward.
The tension between patient-centredness and the organisational imperative of efficiency was also identified by the public health consultant at Fleming:
I don't think the lay person has an idea of what's being done . . . the patient perspective is being overlooked. The question is, is the pathway to manage health service resources better or is it to support the patient better? If there isn't a patient-centred perspective then we could lose the whole point of what patient pathways are for.
Opening up new worlds: territoriality and professional boundaries in the New NHS
Overlying these similarities are some important differences between the pathways, most obviously in the professionals who are included or excluded from them. For instance, maps (i) and (ii) exclude GPs altogether, while maps (iv) and (v) relegate them to the margins of a world that is ophthalmology-centric. Maps (ii) and (iii) introduce new layers of expertise into the traditional mix of services (the ‘elite optometrist’ and the ‘specialist ophthalmic nurse’, respectively), who, not surprisingly perhaps, turn out to play central roles in the care pathways being proposed.
The emergence of hybrid professionals, such as nurse specialists, GP specialists and extended scope physiotherapists, who are increasingly taking on tasks traditionally performed by doctors (or specialists), is one of the key features of contemporary healthcare (Leicht and Fennell 2001). They thus represent a challenge not only to the existing division of clinical labour, but to established hierarchies of prestige and power, and current distributions of reward and resources. In contradiction to the claim that they eliminate professional turf wars (Etheridge 1986), it was perhaps inevitable that pathways would generate opportunities for a remapping of professional boundaries.
Among the emergent hybrid professionals a general sense of excitement was in the air. Reconfiguration of services offered chances to spread their wings, and to explore new ways of working. Part of the attraction was the opportunity for personal development, as the specialist ophthalmic nurse at Brown made clear:
I just think it's nice for the nurse to be able to do more than the basic bedside things. If you've got a special interest in something, it's nice to take that forward, specially in the things that I've achieved. If I'd have stayed a normal nurse, there's no way that I'd have been able to do the things that I do.
Expanding one's professional role in this way, however, was not a selfish matter of personal (or even professional) aggrandisement. It also helped the whole system to function more efficiently, as the GP specialist from Fleming explained:
One consultant, when he looked back, wondered how he coped without us because his local clinic has got a waiting time of over 60 weeks. He traces the amount of work I've done for him in the last couple of years, and he's actually quite pleased.
Thus, pathways furthered the sectional interests of their map-makers without appearing to do so, enabling them to maintain the appearance of neutrality while annexing professional territory (or seeking to do so). We have already noted this feature of pathways in our discussion of the cataract pathway. It emerges even more clearly in the case of the extended scope physiotherapist (ESP) at Brown. Hovering between reality and representation, the map she drew and re-drew, as we talked, placed her centre stage, whilst seemingly off-stage, creating an aura of truth and precision, and absolving her from anything so obvious – or human – as self-interest.
Having received additional training in spinal disorders, the ESP was now sufficiently skilled to undertake 75 per cent of her consultant's traditional workload. Instead of routinely seeing all patients referred to him, and passing on a proportion to her to treat, he now merely scanned the referral letters, enabling him to concentrate on his surgical cases. This had already paid handsome dividends, with waiting times for a consultant appointment reduced to the national target of 14 weeks. Such was the apparent success of this new service model that it was to be rolled out nationally.
Observation in the ESP's clinic, however, revealed how incomplete even her detailed mapmaking and mapping were. For example, her map failed to capture the subtle differentiation that was being created in the process. The ESP's newly developed clinical skills elevated her above those nurse practitioners who, working tightly to protocol, assessed patients for arthritis of the knee and hip; ‘That's a technicians’ job’ she explained. While enhancing her status and skills, and enriching her job, her new managerial and clinical responsibilities simultaneously served to differentiate her from her erstwhile colleagues:
It's taken me away from working with my staff at the coalface, because I would have been in the Department treating patients alongside them. I think they regard me differently. I think they are almost in awe of me . . . Dealing with the turmoil and reaching a new position is what this is all about. The hierarchy means that if you’re at the top, you've got the isolation of being at the top.
At the same time, while she cherished the opportunities for working more closely with her orthopaedic consultant, she did not mix with him socially. Intriguingly, she took the patient's seat at the afternoon's case discussion with him. Thus, as a member of ‘a new species’ the ESP found herself in a quandary, losing some of the camaraderie which she had previously enjoyed working as an ‘ordinary’ physiotherapist: she was betwixt and between (Pinder 2000).
Moreover, in adding texture to the map, she talked about the lack of a mentor, her own stress, and the difficulties of her secretarial staff in keeping up with her increased workload, highlighting the gap between her professional ambitions and the search for resources to nourish them. The calculus of costs and benefits was far from straightforward.
The pathways conveyed little sense of the disputed nature of the boundaries between professions. Each clearly marked box and confident arrow gave the impression that professional tasks and responsibilities were clearly delineated and could be precisely apportioned. A ‘harmony ideology’ (Nader 1990) was being presented, where each professional was working in concert with the others for the common good:
There are no turf wars. We work as part of a team (Consultant dermatologist, Brown).
Pathways were perceived as functioning as tools for consensual decision-making:
They give a structured frame-work; they’re step-by-step plans to cover the things you should be generally thinking about (Nurse educator, Jameson).
Superficially, this dominant ideology of inter-professional harmony appeared to be confirmed by observation, which revealed several instances of team-work in practice, with the specialist ophthalmic nurse dovetailing neatly with ophthalmologists in the adjoining room, for example. However, other evidence suggested that the division of professional labour was not always as consensual or functional as the maps suggested, as the specialist dermatology nurse at Brown explained:
Once you become reasonably confident in your role, when doctors have a busy clinic, they will off-load a little bit. The protocol says that all patients should be seen by a consultant, then by me. But I get asked, ‘Can you see this patient?’ What they forget is that I've never been a doctor, never been to medical school. A keratosis could be something more serious. But we’re trying to find a way round that one. How to negotiate tactfully on that, otherwise mistakes will be made.
Moreover, while the additional professional space opened up by care pathways might benefit some practitioners within the profession concerned, it might be to the detriment of others:
There might be a little bit of friction between those nurses who have not taken on that specialist role and those who have (Consultant dermatologist, Brown).
The optometrist, with an additional layer to his map (Figure 1, map (ii)) talked about the status differentiation between ‘ordinary’ optometrists and
élite optometrists who won't work in the multiples, Boots, SpecSavers, the supermarkets. They really, really don't. Working for a multiple is considered to be the last thing you would ever do. It's both your hands and feet cut off working for a multiple.
Closer examination of the apparent orderliness and functionality of the pathway revealed a number of competing interests:
they should all be working for the good of the patient instead of building their own little empires (GP specialist).
In similar vein, the specialist dermatology nurse in Brown spoke of ‘Lines constantly criss-crossing all over the place’ and of ‘being taken over’ by the newly appointed GP Specialist in Dermatology. Neither was the anticipated colleague-ship between hybrid professionals themselves much in evidence: the specialist ophthalmic nurse at Brown, for example, did not know the ESP only four doors away down the corridor.
Participants were aware of the ambivalent relationship between pathways and reality:
I don't think they create reality because it's already there, all these things are already happening. What health service managers are trying to do is capture it, but they probably refine it too (GP specialist).
At the same time, he acknowledged their power to shape the reality they were supposed to be describing:
It's a descriptive tool, describing variability and attracting resources to it (our emphasis).
Thus, the newly appointed dermatology consultant at Brown (discovered at interview, reducing a busy map to sleeker contours on the advice of the Chief Executive) was anxious to make a mark and reverse the dispiriting trail of ward closures for his specialty. He found the dermatology pathway to be an effective ally in arguing for additional resources:
One of the difficulties is that I don't have my own outpatient clinic. I'm part of the general outpatient clinic, so that I share work and rooms with all the other specialists. I do one day in Clinic One, then another day in Clinic Two, and another day I'm somewhere else. That has the result of £11,000 of equipment being underused.
A follow-up interview revealed that this strategy had worked. An additional consulting room had been secured for his specialist nurse and a GP specialist in dermatology had also been appointed.
Pathways were not only a means of pinpointing where patients were in the system. They were also a way of keeping track of practitioners themselves. Formally, they allowed little latitude for either creativity or unruliness. Thus, the specialist dermatology nurse had less scope to exercise her clinical judgement, although she still prided herself on her ‘holistic’ approach, chasing the Accommodation Officer for parking concessions for her patients, for example: ‘That's my style’. Similarly, while the ESP relished her new responsibilities, she remained subject to the disciplining gaze of her consultant, watchful for mistakes, and a rheumatology GP specialist sceptical of her ability to accurately decipher blood tests. Not surprisingly, some professionals were better placed than others to exploit what opportunities there were. A specialist GP explained her own back pain pathway, for example:
When you’re actually working, everybody has a pathway. Most doctors have a plan of what to do when they see someone with ‘x’, but it isn't necessarily set in stone . . . It's idiosyncratic. It should be standard but we all do different things. We've all got different interests. Ironing out variations might actually bring the standard of care down. When I see someone with a bad back, I probably do more than some of my colleagues would because I'm interested in it – I've got other colleagues who are more interested in, say, asthma, so they would perhaps take more time with asthma patients. This is the thing, that's not a standard pathway that someone has told us to do. That's what I do.
Her independent contractor status afforded this GP a degree of autonomy of practice that was denied to others. Despite the overall shift towards standardised practice, freedom to be creative continued to be distributed along traditional hierarchical lines.
We have seen that the first section of the paper points to the objectification of patients on the maps, glossing the tension between professionals’ desire to respond individually to patients, and the difficulties of doing so. This section has illustrated how professional relationships were also objectified: the relationships that were idealised on the pathways as flow (the arrows) but not overlap (the boxes), actualised as well as reflected notions of appropriate professional distance. In theory, the maps represented them as consensual, orderly and discretely bounded. In practice, map-making and mapping revealed them to be both contested and imprecise.
This paper has drawn on the work of contemporary cultural cartographers to pose some critical questions about the burgeoning use of pathways in contemporary health-care policy. At the same time, we must make it clear that we do not oppose the agenda that informed them in our study sites. We were impressed by the efforts of our participants to reflect critically on their current practice, and to think systematically and holistically about services. We commend what appeared to be a genuine commitment to identifying ‘gaps’ in provision, removing ‘bottlenecks’ and smoothing the passage of patients through the system. As Corner (1999: 213) points out:
We have been adequately cautioned about mapping as a means of projecting power-knowledge, but what about mapping as a productive and liberating instrument, a world-enriching agent . . . ?
Our concern is the modest one of drawing attention to the tensions endemic in pathways as in all ‘rationalising techniques’ (Berg 1997: 157). We simply urge awareness of the way they inevitably reflect and reproduce the very tensions (between efficiency and effectiveness, patient-centredness and organisational or political imperatives) that they strive to resolve. More specifically, are care pathways to be regarded as Taylorist devices for standardising care and treating each individual patient in precisely the same way? Or are they the means of affording individualistic treatment, while simultaneously creating organisational efficiency by ‘tayloring’ the organisation to the patient (rather than the other way round)2? Certainly, our respondents focused on the former interpretation rather than the latter. We, however, would argue that these tensions are inherent in any attempt to fix processes and meanings that are always open-ended and contingent. Hence our emphasis on the notion of a process cartography (Rundstrom 1993: 21), where the pathway is best seen as ‘open-ended, on-going, always leading to the next instance of mapping’. As Ingold (2000) puts it, ‘We know as we go, not before we go’.
We have seen that the care pathways we have been considering systematically omit the plasticity of patients’ personal circumstances and lived experience, providing no map of the terrain that the ill person has to traverse. Thus, there is no space in them for the ‘biographical disruption’ (Bury 1982) entailed by chronic illness – the profound disturbance of taken-for-granted ways of thinking and behaving and relating to the world. Nor is there room for the subsequent task of biographical rebuilding (Siegel and Krauss 1991). Pathways overlook the problem, constant for people with stigmatised conditions such as epilepsy or HIV/AIDS, of ‘managing the secret’ (Caricaburu and Pierret 1995). Nor do they acknowledge that these considerations might influence patients’ decisions about health service utilisation, or that services might possess important symbolic significance. Thus, people with HIV/AIDS might delay (or avoid) transfer to GP care because it signifies the transition from ‘living with HIV’ to ‘dying from AIDS’ (Petchey, Farnsworth and Williams 2000).
Hence, our study suggests that the empowering potential of pathways claimed by Parker (1999) is at best equivocal as far as patients are concerned. Although numerous policy documents emphasise the role of ‘lay’ people in decision-making, and the NHS Plan (DoH 2000) requires that ‘patients must have more say in their own treatment and more influence over the way the NHS works’, we found that a socially conservative vocabulary was being promoted. This paternalism was something which some professionals in the study were both aware of and uneasy about – and, to an extent, wanted to resist. However, whilst pathways enabled clinicians to spot-check where patients were in the system, it was questionable whether they shared this information with patients. Importantly, patients were not invited into the decision-making process: it was practitioners who had the power to make – or un-make – the map. Harvey's (1998) observation that ‘Maps are pre-eminently a language of power, not of protest’ applies equally to care pathways. The voices that they privileged were those of the experts – whether clinicians, managers or auditors (Hogg 1999, Berg et al. 2000). As usual, the voice of patients was muted.
As far as our participants are concerned, we must be careful not to paint too deterministic a picture, and this emerged most strongly in respect of the healthcare practitioners studied. Pathways were important mobilising metaphors, prescribing as well as describing, as the specialist ophthalmic and dermatology nurses and the ESP have illustrated. In practice, however, people don't do the ideal job: they do the do-able job. As embodied practices rather than simply ‘things out there’, they both reproduced the ‘culture’ of the NHS as well as offering scope for redefinition, but differentially along traditional hierarchical lines.
Like other protocols, pathways simultaneously shaped what was happening in practice, and the way practitioners thought about things, embodying and transforming clinical practice, at the same time as they were modified by it. As Berg has argued, contrasting the tool and practice (or map from map-making and map-ping) encourages advocates of the former to exaggerate its universality and to focus on ‘resistance’ to change; and its critics to view the tool as essentially misconceived and exaggerate the inherent superiority of local professional knowledge. Two dangers arise from this. The first is that of seeing ‘blockages’ in terms of professional recalcitrance or personality flaws (the ENT consultant at Fleming), rather than the result of complex, interweaving socio-economic and political factors. In its turn, this may deflect attention away from more appropriate structural reform. Secondly, an obsession with dismantling ‘restrictive practices’ risks undermining the values which hold professional communities together. The subtle layering of hierarchy and responsibility as the new hybrid professionals become folded into an evolving system suggests that professional boundaries are not just bastions of rigidity, but important sources of identity and belonging.
As emphasised earlier, this paper does not refute the good intentions and possible benefits of rational planning per se. Neither is it intended to be an exercise in cynicism. It does, however, question the apparent over-reliance by healthcare planners on pathways as a universal panacea (Bragato and Jacobs 2003). As our study has suggested, there are no cures to demand management that are free from side-effects; every attempt at clarity elicited further grey areas. As Scott (1998) notes:
Any large social process or event will invariably be far more complex than the schemata we can devise prospectively or retrospectively to map it.
The findings point to the need to be flexible and approximate, rather than unbending and absolute, if only because the social circumstances which are routinely confronted are ephemeral, ambiguous and likely to constantly change. Policy-makers’ desire to pin things down, on the other hand, may render practitioners incapable of responding imaginatively to the inevitable unpredictabilities of life.
Hence, our focus on cartography as process always in the making. A lighter touch than the confident images promoted by the pathway may be achievable, one less fervent in pursuit of those tangible outcome points which the pathway dangerously forecloses (Robinson 2001). As Huxley (1949) noted:
The good life can only be lived in a society in which tidiness is preached and practised, but not too fanatically, and where efficiency is always haloed, as it were, by a tolerated margin of mess.
Known also as integrated care pathways, coordinated care pathways, critical care pathways, anticipated recovery pathways or care maps.
We are indebted to an anonymous peer reviewer for this point and this formulation.